In diagnostic imaging, primarily because of the low optical coupling efficiency and the limited sensitivity of video cameras, the use of an x-ray intensifying screen coupled to a camera by a lens is considered suboptimal. Modern electronic x ray acquisition employs image intensification in order to achieve an adequate signal for the camera at the output end of the tube. The high gain of modern intensifiers enables the acquisition of images with noise characteristics limited by the number of detected x-ray photons. However, the advent of ultra- sensitive low-noise CCDs have prompted a re-examination of non-intensified optical coupling approaches for limited applications in medical x-ray imaging where image intensifiers are not optimal. The measured characteristics of a cooled CCD system, with 2048 × 2048 pixels are presented as they apply to the requirements for some x-ray imaging applications. Measurements with a lens coupling suggest that the x-ray quantum limit may be reached in such a system after careful optimization of the components, but much better results may be attained with fiberoptic coupling. The potential merits of intensified versus non-intensified approaches are also discussed.